Healthcare Qualifications Document

HEALTHCARE QUALIFICATIONS DOCUMENT

Provider / Applicant Information

Applicant Name:

Professional Title:    Employer / Organization:

National Provider Identifier (NPI):    Date of Birth:

Licensure and Certification

State of Primary License:    License Number:

Issue Date:    Expiration Date:

Board Certified: Yes

Certification Date:    Certificate Number:

Education and Training

Degree(s):    Graduation Date:

Clinical Privileges and Experience

Current Facility Privileges Held: Yes

Years in Clinical Practice:    Primary Specialty(ies):

Malpractice Insurance and Claims History

Policy Number:    Policy Limits:

Effective Date:    Expiration Date:

Any malpractice claims, settlements or judgments within the last ten (10) years: Yes

Disciplinary and Criminal History

Have you ever had licensure or privileging denied, revoked, suspended, limited or otherwise sanctioned? Yes

Have you ever been convicted of a felony or misdemeanor related to professional practice? Yes

Professional References

Attachments Checklist

Provide copies of the following (check all provided):

Current state license copy    Board certification    Current curriculum vitae

Malpractice insurance declarations    DEA (or controlled substances) certificate    Other

Authorization, Certification and Release

I certify under penalty of perjury that the statements and representations contained herein and in any attachments are true, complete and correct to the best of my knowledge. I authorize any hospital, licensing board, employer, educational institution, insurance carrier, or other entity to release to the applicant organization and its agents any records or information reasonably requested in connection with verification of the information provided. I understand that falsification or omission of material facts may be grounds for denial of privileges, termination, or other disciplinary action.

I further authorize the organization and its authorized representatives to obtain criminal history checks, professional liability claim history, and to make inquiries of references and former employers for the purpose of verifying my qualifications and fitness to perform the duties of the position or privileges requested.

Privacy and Compliance Acknowledgment

I acknowledge that I am subject to applicable federal and state laws and organizational policies governing patient privacy, confidentiality, and the security of protected health information. I agree to comply with all required privacy and security procedures and understand that violations may result in corrective action, up to and including termination of privileges or employment.

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